Research Briefs

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A survey of 517 health care practitioners found that the majority of health care practitioners could not correctly measure the QT interval on an electrocardiogram or correctly identify factors and medications that can prolong the QT interval, which can result in cardiac arrhythmia. Out of 20 questions about the QT interval, the entire group answered a median of 10 questions correctly, and 43 percent measured the QT interval correctly. Physicians in training and academicians were more likely to measure the QT interval correctly.

This paper proposes a framework for measuring the moral or ethical dimension of health inequality. Health inequality is considered avoidable and is defined as health distributions that are not spread equally to every part of a population that is being analyzed. According to the author, measuring health inequity entails three steps. First, one must define when a health distribution becomes inequitable. Second, one must decide on measurement strategies to operationalize a chosen concept of equity. The choice of health measurement, unit of time, and unit of analysis should reflect moral considerations. Third, one must quantify health inequity information following principles rather than convenience.

Although several measures of coexisting illness (cormorbidity) have been developed, the Charlson Comorbidity Index (CCI) remains a particularly popular risk adjustment tool and is often constructed from medical record abstracts or administrative data. This study surveyed 7,761 patients over 4 years and extracted their administrative data. The authors constructed 6 different Charlson indices by using two weighting schemes and 3 different data sources (ICD-9-CM data for index hospitalization, ICD-9-CM data with a 1-year look-back period, and patient self-report of comorbidities). Overall, self-reported Charlson indices predicted 1-year mortality comparably with indices based on administrative data.

This study concludes that results of nucleic acid amplification tests for C. Trachomatis on urine samples are nearly identical to those obtained on samples collected directly from the cervix or urethra. Similar tests can also be used to detect N. Gonorrhoeae. Study results were based on a systematic review of studies from 1991 through 2004, which assessed the sensitivity and specificity of one commercially available nucleic acid amplification test for C. Trachomatis and N. Gonorrhoeae.

Using clinical vignettes, researchers found that pediatricians recommended sepsis workups 82 percent of the time and family physicians 68 percent of the time for infants less than 3 months of age. Sepsis recommendations were more common among pediatricians who completed residency from 1975-1980 and among family physicians who completed residency from 1981-1987, when specialty-specific journals published recommendations for sepsis workups for febrile infants. These findings demonstrate that recommendations published during physicians' residencies may impact their future clinical practices.

Studies using inpatient data often measure care use by the ICD-9-CM code for the procedure in the patientŐs insurance claim. This common practice can lead to biased research results on care use and outcomes, if investigators rely on certain ICD-9-CM codes for procedures that are not required for reimbursement via Diagnosis-Related Group assignment, such as computerized tomography (CT) and magnetic resonance imaging (MRI). Washington State inpatient data for 1997 was used to compare ICD-9-CM procedure and universal billing revenue codes for CTs and MRIs. When compared with revenue codes, ICD-9-CM procedure coding was considerably underreported and variable, with only 33 percent of CT and 43 percent of MRI procedures recorded.

Variation in the treatment prescribed by an individual provider may indicate higher quality of care through better matching of patients to treatments. However, it may also indicate that physicians and patients do not have all the information they need. It is not known how managed care insurance systems respond to provider-level treatment variation.

The authors of this paper developed a theoretical model of insurer behavior when their physicians have variation in prescribed treatments. They tested the model on data from a behavioral health care vendor that had some control over which physicians to select for any given patient. The vendor did not seem to respond to provider-level variance, that is, it did not reward low- or high-variance providers with greater referrals.

Patient-centered communication (PCC) is widely endorsed as a central component of high quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patients' perspective, the psychosocial context, shared understanding, and sharing power and responsibility. In this article, the authors outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. They also propose nine areas for improvement.

Researchers in this study analyzed patterns of physician-patient communication following coronary angiography, particularly as it affects decisionmaking. The pattern suggested a potential cycle of passivity, where certain patients received less information and did less to prompt the doctor for more information. The researchers based their analysis on audiotaped recordings of 93 physician-patient interactions after angiography in a large Veterans Affairs medical center. The interactions were very brief and were dominated by physicians, who gave more information when the patient actively participated. Physicians gave less information to black than white patients, and black patients tended to actively participate less often than white patients.

The presenting complaint of children visiting the emergency department (ED) drives much of triage decisionmaking, the direction and extent of history taking, physical examination, and diagnostic testing. This paper describes the development of the Pediatric Emergency Reason for Visit Cluster system, a system for grouping complaints presented in the ED.

Using data on pediatric visits from the National Hospital Ambulatory Medical Care survey for 1998 and 2000, the researchers generated 52 clusters; only 2.4 percent of complaints were classified as other. Eight of the most common clusters encompassed 52 percent of visits. The top five were fever, extremity pain/injury, vomiting, cough, and trauma. In addition, the complaint clusters were associated with actual resource use. Researchers found that both resource use and triage classification increased when the complaint was ranked as more severe.

Many researchers advocate use of hierarchical statistical models for health services research. These multilevel models or random-effects models analyze data that are nested, for example, patients nested within hospitals. However, the models are computer-intensive and complicated to perform. This study compared the ability of standard logistic regression relative to hierarchical modeling in predicting risk-adjusted hospital mortality rates for coronary artery bypass graft (CABG) surgery in New York State. Based on that State's CABG registry data from 1994 to 1999, standard logistic regression performed similarly to hierarchical models.

Welfare reform in 1996 replaced the Aid to Families with Dependent Children program with the Temporary Assistance to Needy Families (TANF) program, which emphasizes leaving welfare for paid employment. However, 25 to 50 percent of former TANF recipients and 15 to 30 percent of their children become uninsured after the expiration of the transitional Medicaid coverage they receive for one year when leaving welfare. Using data from 90 face-to-face interviews, this paper explores the expectations, plans, and coping strategies of TANF recipients in Oregon, who are in the middle of the transitional coverage year. It shows that TANF recipients often incorrectly assume their Medicaid coverage will continue after the transitional year, and many have no plans for securing health insurance.

This study found that, among British civil servants, lower position in the social hierarchy and low job control are associated with a higher incidence of coronary disease. Researchers examined heart rate variability (HRV) among 2,197 male civil servants aged 45 to 68 years in various employment grades (social position) and the psychosocial, behavioral, and metabolic risk factors for coronary disease previously found to be associated with low social position. Low employment grade was associated with higher heart rate and lower HRV. Lower HRV was also associated with smoking, little or no exercise, poor diet, and high alcohol consumption.

Inadequate initial antibiotic therapy is an independent risk factor for death from infections due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK), concludes this study. The researchers retrospectively determined whether inadequate initial antimicrobial therapy (IIAT, more than 48 hours between the time a culture was obtained and initiation of an agent to which the infecting organism was susceptible) was associated with mortality among hospitalized patients with an ESBL-EK infection between June 1, 1997 and December 31, 2002. Patients with IIAT who had nonurinary ESBL-EK infections were ten times more likely to die than those with urinary infections.

Although men make up a large majority of veterans who receive care in the Veterans Affairs (VA) health care system, women now comprise nearly 10 percent of the 4 million users and this number is rapidly rising. Researchers found that outpatient VA care for women is equal to that of men for general preventive services and specific services for diabetes and hypertension, as well as the use of beta-blockers or aspirin for a prior heart attack.

This article describes the process of unsolicited requests—communications from managed care plans to drug companies for information—and its potential impact on the use of economic evidence in formulary decisions.In the past, managed care plans have resisted using economic evidence to make drug formulary decisions. However, this has changed in recent years as health plans have begun to adopt evidence-based and value-based formulary submission guidelines. The author believes that the guidelines have the potential to serve as a national unifying template for pharmacy and therapeutics committees to consider clinical and economic information in a systematic rigorous fashion. However, many questions remain about their use and about the nature of unsolicited requests.

The findings in this study indicate that children commonly suffer from bacterial infections after hematopoietic stem cell transplant (HSCT), despite the use of gut decontamination (GD) with antibiotics. Researchers retrospectively studied 182 pediatric patients undergoing their first HSCT for cancer, who received GD at one children's hospital from 1999 to 2002. They examined the impact of several factors on infection, including stem cell source, donor, recent bacteremia, and graft versus host disease prophylaxis agents. Overall, 41 percent of patients developed bacterial infections. The majority were Gram-positive cocci, consistent with recent trends in immunocompromised patients.

This study examined whether race, language, or sex concordance between primary care providers (PCPs) and patients was associated with lower missed appointment rates in neighborhood health centers. Researchers also determined whether site of care was a determinant of missed appointment rates. Patients whose race and language were similar to their PCPs and patients whose PCPs had greater availability of appointments were less likely to miss appointments.

The first paper examines associations between social, economic, and health system characteristics and individual reporting of having a usual source of health care. Although individuals' current health, insurance status, income, demographics, educational attainment, and social support were closely associated with having a usual source of care, so were characteristics at the county level, such as poverty and degree of urbanization. The second paper examined the relationship between health care system characteristics, other social and economic characteristics of counties in a midwestern U.S. State, and an individual's ability to meet health care needs over a 12-month period.

Inclusion of ethnic minorities in clinical research is vital to addressing ethnic disparities in health. This study found that household contact and individual response rates to trial recruitment efforts differed by ethnicity and language. Researchers conducted a telephone survey on physician-patient communication and randomized the responses to examine the effects of ethnically tailored initial contact letters on response rates among adult general medicine patients. Response rates were highest among Spanish-speaking Latinos (75 percent), lowest for whites (66 percent), and intermediate for blacks (70 percent) and English-speaking Latinos (68 percent).

These authors examined 512 cost-utility analyses published in the United States and other developed countries from 1976 through 2001 for analyses on disease rankings and the extent to which these analyses covered key Healthy People 2010 priorities. Researchers found that the analyses focused mostly on pharmaceuticals (40 percent) and surgical procedures (16 percent). The data showed overrepresentation of analyses for cerebrovascular disease, diabetes, breast cancer, and HIV/AIDS, and under-representation for depression and bipolar disorder, injuries, and substance abuse disorder.

The first study validated a previously published out-of-hospital clinical decision rule to identify seriously injured children involved in motor vehicle crashes (MVCs). The rule included 15 variables, including Glasgow Coma Scale score, vital signs, and vehicular and crash characteristics to identify children as seriously injured or needing specialized trauma care. The decision rule identified all seriously injured children involved in MVCs and had moderate specificity. It was less sensitive for identifying children requiring specialized trauma care. The second study described the institutional variability in obtaining Federal assurance documents or agreements to comply with Federal research regulations among the hospitals participating in the out-of-hospital clinical decision rule for children involved in MVCs.

The probability of serious thoracoabdominal (chest and abdomen) injury increases with increasing proximity of seat position to the side of a motor vehicle crash (MVC). Also, the risk of thoracic injury is higher than abdominal injury for all seat positions. Researchers analyzed data from the National Automotive Sampling System Crashworthiness Data System from 1995 to 2003 on occupants aged 16 years and older involved in MVCs. They examined the relationship between seat position, side of lateral MVC, and serious thoracoabdominal injury. Overall, 2 percent of people had serious thoracic injuries and 0.5 percent had serious abdominal injuries.

Antiparkinsonian medication is often prescribed for people with schizophrenia to control involuntary movements caused by typical antipsychotic medications. Researchers examined the effects that switching from typical to atypical antipsychotic medications and from one typical antipsychotic medication to another had on prescribing antiparkinsonian medication among people with schizophrenia. Antiparkinsonian medication prescribing dropped by 9 percent after switching from typical to atypical antipsychotics. However, the reduction varied according to type of medication. For example, switching to olanzapine decreased the rate by 19 percent, but switching to risperidone had no impact. After switching from one typical antipsychotic to another, antiparkinsonian medication prescribing increased by 13 percent.

To control prescription drug costs, most health plans limit prescriptions, including those for chronic conditions, to a 30-day supply when they are filled at community pharmacies. This study examined dispensing patterns for five drug classes commonly prescribed for chronic conditions. Dispensing patterns differed by drug class, insurance type, and socioeconomic status. For example, disadvantaged and Medicaid-insured individuals were more likely to get 30-day supplies rather than larger quantities. Among privately insured individuals, those with drug coverage were more likely to obtain 30-day supplies than those without drug coverage.

According to this study, stratifying health care populations based on measures of health severity is a powerful method to achieve more accurate cost predictions. A model was developed using 1999 Georgia Medicaid claims data that assigned Medicaid-insured pediatric patients to health severity classes. These classes were used to stratify a traditional two-part risk-adjustment model to predict inpatient Medicaid expenditures. The model identified four classes of children: a majority healthy class and three illness classes with increasing levels of severity. Stratifying the traditional model by health severity classes improved its predictive power from 0.17 to 0.25.

Abstracts of published journal articles on cost-effectiveness analyses (CEAs) often omit data elements critical to proper study interpretation, conclude the authors of this study. Researchers reviewed the medical literature from 1998 through 2001 for original CEAs to examine the extent to which the article abstracts included key data elements and to assess the effect of journal characteristics on reporting quality. Among the 303 abstracts reviewed, a clear description of the intervention was present in 94 percent, comparator (the alternative to the intervention) in 71 percent, target population in 85 percent, and study perspective in 28 percent. All four data elements were reported in only 20 percent of abstracts and three elements in 49 percent.

Hospitals that participate in a quality improvement organization (QIO) program are no more likely to show improvement on quality indicators than hospitals that do not participate, concludes this study. Researchers examined data from four QIOs charged with improving the quality of care in five States. They examined medical records of about 750 Medicare beneficiaries per State in five clinical areas in 1998 (baseline) and again in 2000-2001 (followup). They compared improvements in quality of care for patients in hospitals that actively participated with the QIOs versus hospitals that did not. There was no significant difference in change from baseline to followup between both groups of hospitals on 14 of 15 quality indicators.

Researchers found that the Pain Disability Index (PDI) is a reliable measure of pain-related disability that can also be administered by telephone. Using computer-assisted telephone interviews with 1,329 Missouri workers' compensation claimants who had occupational low back injuries, researchers examined the factor structure of the PDI and the effects that race and sex had on the PDI. Results for the total sample and by race/sex group indicated support for a two-factor model of the PDI corresponding to voluntary activities (for example, social, occupational, and recreational) and obligatory activities (for example, activities of daily living, eating, and sleeping). There was adequate reliability and construct validity overall and in each of the race/sex groups.

Methodology for causal inference based on propensity scores usually concentrates on binary treatments. Only recently have these methods been extended to settings with multi-valued treatments. The authors of this paper propose a number of discrete choice models for estimating the propensity scores. The models differ in terms of flexibility with respect to potential correlation between treatments and, in turn, the accuracy of the estimated propensity score. The authors present the effects of discrete choice models used on performance of the causal estimators through a Monte Carlo study. They also illustrate the use of these models to estimate the effect of antipsychotic drug use on the risk of diabetes in adults with schizophrenia.

The Clinical Laboratory Improvement Amendments of 1988 require that laboratories perform cytologic-histologic correlation. Researchers found that laboratories have different ways of recording data from the cytologic-histologic correlation process, indicating a lack of standardization. Out of 15 key variables that could be used in performing cytologic-histologic correlation, only cytology case number, sign-out cytology diagnosis, surgical pathology case number, and sign-out surgical pathology diagnosis were recorded by more than 50 percent of laboratories. Nine (17 percent) labs did not record data on forms, logs, or tally sheets.

The authors of this article developed characteristics of social reality constructs that are held by the major stakeholders participating in policy debates about global trade, public health, and health services, through reviews of the published literature, interviews with key informants of major organizations, and organization reports. Social constructs concerning trade and health reflect broad ideologies when considering the impact of market processes. For example, the U.S. Government assumes that by expanding the private sector, improved economic conditions will improve overall health with a minimum government provision of health care. International financial institutions emphasize reforms that include reduction and privatization of public sector services. Advocacy groups emphasize the deleterious effect of international trade agreements on public health and health services.

Researchers found that quality improvement (QI) interventions with either medication management or psychotherapy improved outcomes for primary care patients with depressive disorder and subthreshold depression (depression that does not meet full diagnostic criteria) when compared to usual care. QI interventions also decreased the number of mental health visits for those with subthreshold depression. These results highlight the feasibility of including patients with subthreshold depression in such programs.

Despite changes in the structure of the U.S. health care system, patients continue to need and seek out generalist physicians. Yet, fewer U.S. medical school graduates are entering generalist residency training—less than 40 percent in 2004. This article reviews the history of and trends in physician career choice and proposes four evidence-based recommendations to rekindle student interest in generalist careers. The authors suggest improving satisfaction and enthusiasm among generalist physician role models and that schools of medicine redouble their efforts to produce primary care physicians. They also recommend facilitating the pathway from medical school to generalist residency and increased U.S. Government funding for primary care research and research training.

Veazie, P.J., Johnson, P.E., O'Connor, P.J., and others (2005). "Making improvements in the management of patients with type 2 diabetes: A possible role for the control of variation in glycated hemoglobin." (AHRQ grants HS11919 and HS10639). Medical Hypotheses 64, pp. 792-801.

The authors of this paper hypothesize that physician treatment strategies influence variation in glucose levels, and that this variation provides an independent contribution to the risk of diabetes complications. The authors suggest that development of treatment strategies to control variation may be a beneficial goal in the management of type 2 diabetes. Using observational data from a large multispecialty medical group, they characterize patient trends and variation of glycated hemoglobin in adults with type 2 diabetes, describe patterns of variation, and identify factors associated with variation.

The Whitehall II studies of British civil servants (aged 35-55 years in 1985-1988) were originally designed to investigate social and occupational influences on health and illness. Recent analyses of over 15 years of data confirm the inverse relationship between socioeconomic position (indicated by employment grade) and coronary heart disease (CHD), diabetes, and metabolic syndrome. The first study provides an overview of the Whitehall II study. The second study reveals strong associations between self-reported job insecurity and both poor self-rated health and minor psychiatric problems. According to the third study, there is an employment grade gradient in plasma viscosity, which was not fully explained by health-related behaviors or measured risk factors for CHD. The fourth study suggests that cognitive ability explains only part of the relationship between socioeconomic position and health.

These authors examine issues involved in estimating clinically significant differences in quality of life (QOL) outcomes, based on a review of six articles written by 30 international experts in the field of QOL assessment and evaluation. They conclude that no single method for determining clinical significance is unilaterally endorsed. The authors discuss prerequisites for clinical significance associated with instrument selection, responsiveness, and the reporting of QOL trial results. They also discuss estimating the number needed to treat relative to clinically significant thresholds. Finally, they provide a rationale for applying group-derived standards to individual assessments.

This study compared the clinically important difference (CID) thresholds for change over time on the eight scales of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), Version 2. These thresholds were developed by three separate expert panels of physicians with experience in health-related quality of life assessment among patients with chronic obstructive pulmonary disease, asthma, and heart disease. All three panels agreed on the scale changes that constituted small, moderate, and large clinically important SF-36 change scores for these diseases. If confirmed among patients with the relevant diseases and their physicians, these disease-specific CIDs could aid researchers and practicing clinicians in the use and interpretation of health-related quality of life changes over time.

This article describes and provides examples of approaches the authors have used to identify minimally important differences (MIDs) for instruments in the Functional Assessment of Chronic Illness Therapy (FACIT) measurement system. Health-related quality of life (HRQOL) is an important endpoint in cancer clinical trials and for cancer treatment in general. However, the meaningfulness of HRQOL scores may not be apparent to clinicians or
researchers. MIDs can enhance the interpretability of HRQOL scores by identifying differences likely to be meaningful to patients and clinicians.

Researchers often compare the differences for some measures between two groups, such as the drug effect between a treatment group and control group or the health outcome between intervention A and intervention B. The authors of this article evaluate several existing statistical techniques and propose new methods to improve coverage accuracy.